Form 207 Worksheet - Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy

Worksheet only. Not the official form. Transfer to Official Form 207 or e-filing software. For corporations/LLCs/partnerships.

United States Bankruptcy Court
District of [District]

In re: [Debtor Name]
Case No.: [if known]
Chapter: [7/9/11/12]

Part 1: Income

• Gross revenue from business (this year-to-date): $[ ] (from [date] to petition date)
• Gross revenue from business (prior year): $[ ]
• Gross revenue from business (two years ago): $[ ]
• Other income (non-business) for same periods: [ ]

Part 2: Financial Transactions

• Transfers outside ordinary course within 2 years: list recipient, date, description, value received: [ ]
• Payments/other transfers to insiders within 1 year: [ ]
• Setoffs within 90 days (1 year for insiders): [ ]

Part 3: Legal Actions, Repossessions, Foreclosures

• Pending/closed lawsuits, administrative proceedings, arbitrations (within 1 year): court/agency, case no., nature, status: [ ]
• Property seized/levied/garnished/foreclosed/repossessed in last year: [ ]

Part 4: Assignments/Receiverships/Transfers

• Assignment for benefit of creditors or receiver/custodian within 1 year: [ ]
• Property transferred after petition filed (if any authorized): [ ]

Part 5: Banking and Books

• Financial accounts closed/held at filing (last year): institution, type, ending balance/last statement: [ ]
• Safe deposit boxes/storage units (contents and location): [ ]
• Books, records, and financial statements: who has them; custodians: [ ]

Part 6: Inventories and Assets

• Inventory conducted within 2 years: date, who supervised, method, value: [ ]
• Environmentally sensitive property/hazardous material sites: [ ]

Part 7: Officers, Directors, Owners

• Current officers, directors, managing members/partners (names, addresses, titles): [ ]
• Former officers/directors/managing partners within 1 year: [ ]

Part 8: Debtor History

• Withdrawals/distributions to equity within 1 year: [ ]
• Address changes in last 3 years: [ ]
• Prior business names/locations in last 8 years: [ ]

Part 9: Certain Financial Accounts and Safe Deposits (detail as required)

• Deposits/prepayments for property/services not delivered (last year): [ ]
• Setoffs; trusts for another party: [ ]

Declaration

I declare under penalty of perjury that the answers are true and correct to the best of my knowledge, information, and reasonable belief.

Authorized representative of debtor:
- Name/Title: [ ]
- Signature: __________________________ Date: __________
- Address/Phone/Email: [ ]